Provider Demographics
NPI:1912066929
Name:WEINER, J.PAMELA (PHD,LP)
Entity Type:Individual
Prefix:
First Name:J.PAMELA
Middle Name:
Last Name:WEINER
Suffix:
Gender:F
Credentials:PHD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-822-9770
Mailing Address - Fax:612-823-6090
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:SUITE 410
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-822-9770
Practice Address - Fax:612-823-6090
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2434103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680000196Medicare ID - Type UnspecifiedPSYCHOLOGIST